https://podcasters.spotify.com/pod/show/opotikigp/episodes/Clinical-Snippets-May-2023-e24n5fn

Clinical Snippets May 2023

1.  Pelvic Mesh Complications

• Te Whatu Ora female pelvic mesh complications service is a national service for people born with biologically female pelvic organs, who may have been harmed by mesh implanted for the treatment of urinary stress incontinence or pelvic organ prolapse.  The Te Whatu Ora website provides comprehensive information regarding the service including downloadable GP flyer and infographic of how the process works.

• Care and support options include continence care, chronic pain management, counselling, and surgery. Care is provided by a multidisciplinary team including physiotherapists, social workers, psychology services, surgeons, pharmacist, sexual health therapist, pain medicine specialists, nurses, health navigator, and dietitian.   Services are located in Auckland and Christchurch. Transportation and accommodation assistance may be available.

• Specific referral information is available via HealthPathways (New Zealand Female Pelvic Mesh Service Requests)with more information in a recent eReferrals newsletter. 

2.  PSA Testing

GP Research Review issue 2 2023  comments on the USANZ position statement on PSA testing.      This position statement serves as an interim document for the optimised use of PSA testing in Australia and New Zealand until current guidelines on PSA testing are updated. The USANZ New Zealand section is working on new PSA guidelines to be released later this year as the 2015 guidance is now outdated and inconsistent with contemporary clinical practice.

Recommendations include:

• Ensure prostate cancer awareness amongst men and counsel them on the potential risks and benefits of PSA testing.

• Offer an individualised risk-adapted strategy for early detection of prostate cancer in men aged >50 years of age with a life expectancy of at least 10 years.

• Offer early PSA testing to men at an increased risk of prostate cancer:
  • Men >45 years of age with a family history of prostate cancer
  • Men of high-risk ethnicities (including Indigenous men) >45 years of age
  • Men carrying BRCA2 mutations >40 years of age

• Stop early diagnosis of prostate cancer based on limited life expectancy and poor performance status; for example, men with a life expectancy of <10 years are unlikely to benefit.

• For men with an initial PSA test of >3 ng/mL, the use of risk stratification (considering factors such as age, family history, digital rectal examination and PSA density) can help guide the need for further testing, including MRI and biopsy.

3.  Polypharmacy

Issue 3 of GP Research Review looked at a recent article published in the Journal of Primary Health Care with a focus on polypharmacy.

• A total of 61 indicators for inappropriate medicines prescribing in polypharmacy that are relevant to people aged over 65 years in New Zealand were identified, and form the “New Zealand Criteria”. Indicators that were considered ‘very important’ or ‘important’ in New Zealand were similar to published international criteria.

• Medicines that were identified as being of particular concern included NSAIDs, benzodiazepines, anticholinergics, antipsychotics and first-generation antihistamines. There were two indicators that reached 100% consensus: a combination of three or more CNS active medicines (e.g., antidepressants, antipsychotics, antiepileptics, benzodiazepines, zopiclone, opioids); and the use of long-acting sulfonylureas (e.g., glibenclamide). Eight out of nine experts agreed that it was very important to correct the prescribing of alpha blockers in older patients with postural hypotension and NSAIDs in older patients with stage 4 chronic kidney disease or higher.

• A complete list of potentially inappropriate medicines indicators is available in the full article.  A 2018 BPAC article contains useful resources for de-prescribing including a discussion on pharmacist services (eg Medicines Therapy Assessment) available in some areas. 

4.  New COPD guidance

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has published updated guidelines on chronic obstructive pulmonary disease (COPD).  The guidelines include several important changes, particularly concerning the use of long-acting bronchodilators in treatment.

• LABA/LAMA combination treatment is now recommended as first-line treatment in patients requiring a long-acting bronchodilator, including those who are more symptomatic or at high exacerbation risk. This supersedes previous guidance to use LAMA or LABA monotherapy first.

• Use of an ICS + LABA alone is now discouraged throughout COPD management unless prescribed for a concurrent diagnosis such as asthma, and a more targeted approach for ICS use is suggested.

• A revised “ABE” assessment tool for predicting patient outcomes and making treatment decisions. This recognises the clinical relevance of exacerbations, regardless of the patient’s symptom severity (i.e. categories “C” and “D” in the “ABCD” tool are now combined into a single “E” category).

• BPAC have previously provided useful COPD tools for assessment and management and note the following:  Given these significant changes, we plan to update our COPD tools. However, we will await any revision of New Zealand guidelines in accordance with the GOLD 2023 report. In addition, Special Authority approval criteria for LABA/LAMA combinations currently require patients to be stabilised on LAMA monotherapy first, making these recommendations difficult to apply equitably in practice.

5.  Type 2 diabetes

• A Dutch study reviewed in Issue 167 of the Diabetes and Obesity Research Review looked at use of SGLT-2 inhibitors in very-high cardiovascular risk patients with type 2 diabetes.  Only 10.3% of such patients were being prescribed SGLT-2 inhibitors despite being eligible under national guidelines.  Of those not prescribed the medication, there was no contraindication to prescribing in over 70% and none were on a GLP-1 agonist.  The reviewer notes SGLT-2 inhibitors have been available in the Netherlands for longer than they have here in NZ and wonders how well we are performing by comparison. 

• An excellent algorithm for management of patients with type 2 diabetes which incorporates prescribing of SGLT-2 inhibitors and GLP1 receptor agonists is available on the NZSSD website and can be downloaded as a PDF.  Further resources including interpretation and application of Special Authority criteria are available on the Pharmac website. 

• The EPIC dashboard on Te Ako Hiringa enables you to compare your prescribing for type 2 diabetes with those of your practice colleagues and national data and includes data on patient adherence to prescribed medication and tips for improving diabetes medicines equity. 

• The University of Waikato and New Zealand Society for the Study of Diabetes are running a free online diabetes management course starting 17 July 2023. The course is run over 20 weeks, made up of eight 30-minute webinars and eight 30-minute case discussion and mentoring sessions. The course is approved for 16 hours CME points.

6.  Vitamin D and diabetes

• A recent Goodfellow Gem commented on a study suggesting Vitamin D may reduce risk of diabetes in pre-diabetics.  The review and metanalysis of individual patient data from three trials reported a reduction of 3% in absolute risk of progression to diabetes. The comparable doses from two studies were 80,000 units 4 weekly and 120,000 units 4 weekly; the NZ option is 1.25 mg cholecalciferol tablet = 50,000 units once per month.

• There was an improvement with higher blood levels of Vitamin D, with the greatest reduction with a blood level of ≥ 125 nmol/l (18% absolute risk reduction). There appeared to be no adverse effects, but studies were not powered to detect these (but remember Vitamin D is fat soluble and can be toxic in overdose – usually serum levels >375 nmol/L).  The NNT to prevent diabetes is 30 (compared with 7 for intensive lifestyle and 14 with metformin). It was mainly effective in those with BMI < 31.3 Kg/m. The study ethnicities were European 50% and Asian 33%, so no Māori or Pacific patients.

• The same study was reviewed in Issue 212 of GP Research Review with the reviewer concluding:  Impressive, and I am going to be prescribing it for my prediabetics, can’t do any harm. 

7.  Topiramate in pregnancy

Medsafe have put out a further alert regarding use of topiramate in pregnancy and women of childbearing age.  Congenital malformations and neurodevelopmental disorders have been reported in children following in utero topiramate exposure.

Advice to health professionals includes: 

• Topiramate should only be used to treat epilepsy in pregnancy if the potential benefit justifies the potential risk to the mother and fetus.
• Refer epileptic women taking topiramate who become or plan to become pregnant for specialist advice.
• The use of topiramate for migraine prophylaxis is contraindicated in pregnancy.
• Perform pregnancy testing before starting treatment. Women of childbearing potential should use a highly effective contraceptive method during treatment.
• Inform women of childbearing potential about the risks of fetal harm if they become pregnant.

8.   Progestagen only contraception and risk of breast cancer

• A recent BPAC update bulletin notes previous studies have established that patients taking combined oral contraceptives are at slightly increased risk of breast cancer. Progestogen-only contraceptives have been considered an alternative option for patients where oestrogen is not recommended or contraindicated, however, the data regarding breast cancer risk and progestogen-only contraceptives has been inconsistent. A recently published study based in the United Kingdom (UK) now suggests that the risk of developing breast cancer in patients who take progestogen-only contraceptives is comparable to those taking combined hormonal contraceptives.

• While it is recommended that the new information is included when discussing the risks and benefits of contraceptive options with patients, the UK-based Faculty of Sexual and Reproductive Healthcare (FSRH) have not currently recommended any major changes to clinical practice in response to the study.

• Best practice tip: The absolute risk of breast cancer with progestogen-only contraceptive use is still very small, especially in younger patients with no familial breast cancer risk. The decision to prescribe any type of hormonal contraception should consider this low risk in the context of the possible benefits of use, e.g. reduced risk of an unplanned pregnancy and other non-contraceptive benefits such as reducing the risk of endometrial and ovarian cancers.

9.  Prescribing for ADHD

(i)  Pharmac has announced the General Rules of the Pharmaceutical Schedule will be amended from 1 June 2023 to allow three months of the stimulant/ADHD treatments, methylphenidate and dexamfetamine, to be funded when prescribed electronically.  While the Regulations allow electronic prescriptions for methylphenidate and dexamfetamine to be issued for three months at a time instead of one month, the frequency of dispensing for these medicines remains monthly. 

(ii)  The RANZCP has a statement on guidance for the use of stimulant medications in adults  (2015) which includes:  Specific caution, including appropriate monitoring, is required in the consideration of stimulant prescription to persons who have a history of substance abuse or dependence… Clinicians should assess and monitor the risk associated with stimulant prescription in adults with a history of hypertension, cardiovascular or cerebrovascular disorders. A baseline electrocardiogram (ECG) should be performed if there is a family history of serious cardiac disease or sudden death in young family members, or abnormal finding on cardiac examination. The patient’s blood pressure should be regularly monitored during the course of treatment with stimulant medication.

(iii)  New Zealand Formulary includes the following screening and monitoring advice for methylphenidate:

Pre-treatment screening 

• Obtain a detailed psychiatric history including family history of suicide, bipolar disorder, and depression
• Assess for risk of misuse (including family and caregivers)
• Assess for personal or family history of tics or Tourette’s syndrome
• Assess cardiovascular function including blood pressure and heart rate—seek specialist cardiac advice if history of, or current, cardiovascular disease
• Assess for family history of sudden cardiac or unexplained death or malignant arrhythmia
• Measure height and weight 

Monitoring requirements 

• Monitor for development or worsening of pre-existing psychiatric disorders, aggressive behaviour, anxiety or agitation at the start of treatment, at every dose adjustment, and at least every 6 months—consider discontinuing treatment if psychiatric disorders develop or worsen
• Monitor for emergence or worsening of tics or Tourette’s syndrome at every dose adjustment and at every clinic visit—consider discontinuing treatment if tics develop or worsen
• Monitor for misuse
• Monitor cardiovascular status including blood pressure and heart rate at least every 6 months and at every dose adjustment—seek prompt cardiac evaluation if palpitations, exertional chest pain, unexplained syncope, dyspnoea or other symptoms suggestive of cardiac disease occur
• Assess weight and appetite at least every 6 months
• Closely monitor patients at risk of acute angle-closure glaucoma
• Monitor full blood count, differential and platelet counts during prolonged therapy as clinically indicated.
• Consider de-challenge at least once yearly 

https://podcasters.spotify.com/pod/show/opotikigp/episodes/Clinical-Snippets-April-2023-e24n53a

Shownotes

Clinical Snippets April 2023

1.  Syphilis

(i)  A recent Te Whatu Ora Waikato newsletter notes here has been a sharp increase in infectious syphilis notifications during 2022. This is particularly in the upper half of the North Island including Waikato and largely due to a sharp rise in reported cases among men. Notifications among men who have sex with women (MSW) have more than doubled between 2022 Q1- 2022 Q3. Infectious syphilis notifications among Māori MSW more than tripled. Notifications among men who have sex with men (MSM) increased by 40%.

(ii) The number of infectious syphilis notifications among women of reproductive age (15-49) and pregnant women remain high. In Q3 about half of the women who have sex with men (WSM) notified were pregnant – we are not testing enough young women.  Congenital syphilis (CS) notifications remain high and individuals of Māori ethnicity continue to be overrepresented in maternal and CS cases.

(iii)  HealthPathways recommends testing for syphilis in the following situations:

• All patients having a routine sexual health check. Recommend a repeat test 3 months from the time of last sexual intercourse if particular concern.
• All pregnant women (first antenatal bloods). Offer re-screening between 28 to 38 weeks gestation for women at increased risk: who have had a new sexual partner during pregnancy; with more than one sexual partner during pregnancy; with an STI diagnosed during pregnancy; whose partner is diagnosed with an STI.
• All MSM, especially if HIV positive. Arrange serology at least annually.
• Any rash or genital symptoms in MSM
• HSV genital ulcer(s), atypical or non-healing genital ulcer(s)
• Unusual clinical presentations e.g., lymphadenopathy, unexplained abnormal liver function tests, alopecia, pyrexia of unknown origin
• Patients who have had sexual contact with a person diagnosed with syphilis (serology usually carried out by sexual health clinic)

(iv)  Syphilis can be asymptomatic. Consider syphilis testing in cases with unusual skin rashes, oral, genital or perianal ulcers, lymphadenopathy, hepatitis and/or neurological symptoms. Syphilis in its secondary stage can affect any body system and cause end organ damage, hence its reputation as the ‘Great Pretender’.   Management guidelines can be accessed through HealthPathways and the Aotearoa New Zealand STI Management Guidelines. 

2.  Verifying death

(i)  The Ministry of Health Guidelines for Verifying Death note that medical practitioners, nurse practitioners, registered nurses, enrolled nurses, midwives, emergency medical technicians, paramedics and intensive care paramedics are authorised by the Chief Coroner to verify death, including deaths which meet the criteria for reporting to the Coroner.  

(ii)  A health practitioner can verify death when:

• the body shows signs of rigor mortis incompatible with life, or
• the body has visible injuries incompatible with life, or
• the body shows signs of decomposition incompatible with life.

Alternatively, health practitioners can verify death once they have undertaken two assessments (a minimum of 10 minutes apart) to establish death. The health practitioner must confirm the following:

• no signs of breathing for one minute (requires exposure of entire chest and abdomen)
• no palpable central pulse (femoral, carotid or brachial). In most circumstances this will

require palpation for 5–10 seconds

• no audible heart sounds
• pupils dilated and unreactive to light (requires a focal light source eg a torch)
• where available, a cardiac monitor or defibrillator is used and shows asystole

The reason given for the second assessment is that the person may be in asystole for 5–10 minutes and then spontaneously develop return of a beating heart. This is sometimes called auto-resuscitation or the Lazarus reflex.

(iii)  Medical practitioners and nurse practitioners can now use Death Documents to report deaths to the coroner. This new function asks a series of screening questions to guide the practitioner through the reporting requirements then provides a firm recommendation to either complete and submit a Coroner Report or complete a medical certificate of cause of death (because the death does not need to be reported to the coroner).  GPs have previously phoned the coroner to report a death. They are now encouraged to report the death using Death Documents.  The coroner’s office (NIIO) is notified immediately, and the death is reported to Te Whatu Ora so that the NHI record can be updated with the date of death.  NIIO will register the report and contact the practitioner by phone within 2 hours to confirm whether they have taken the case.  If the coroner decides to investigate the death, you must notify the police of the death if they are not already involved.

3.  Opioid prescribing

A recent BPAC article on opioid prescribing (Quick reference here) includes some potentially useful resources related to the prescribing recommendations, and an oxycodone prescribing audit which can be used for Te Whanake CPD credits.  There is a link to the Live Well with Pain website which is an initiative developed by clinicians in the United Kingdom. It includes a comprehensive suite of freely available resources designed to inform and support health professionals working with patients who have persistent pain and to help guide the appropriate use of opioid medicines.  Free registration is required. 

Key recommendations in the BPAC article include:

• Establish a treatment plan when initiating an opioid, including measurable goals and the timeframes for achieving these, information about adverse effects and a plan to stop use. This jointly agreed plan can be verbal, but it should be documented in the patient notes. BPAC has provided an editable pain management plan template.

• In some cases, a formal written and signed opioid contract may be suitable to ensure safe and effective opioid use.  BPAC has provided an example opioid contract if you think it might be suitable for a specific patient.

• Ideally select an immediate release formulation due to the lower risk of sedation, respiratory depression and overdose (particularly during initiation). Modified-release opioids are a strong risk factor for opioid dependence. N.B. modified-release formulations may still be considered in certain scenarios depending on clinical judgement.

• Use the lowest potency and dose possible to effectively manage pain. Reassess the benefits and risks of treatment when considering each dose increase if pain is insufficiently controlled. Prescribe in combination with non-opioid analgesics and/or adjuvant medicines as this may reduce the dose of opioid required to achieve pain relief.  Be alert for potential signs of misuse and dependence, e.g. requests for early repeats or escalating doses

• If initiation of a strong opioid is being considered in primary care, ensure morphine is trialled first before prescribing oxycodone (unless the patient has a documented allergy or intolerance)

• Prescribe for the shortest possible duration (ideally three days or less). If this is not practical and longer-term use is required, advise intermittent dosing (i.e. as-needed within the daily dosing limits), rather than continuous use. Intermittent dosing reduces the risks of dependence without compromising potential benefits.

• Prescribe a laxative if use will exceed 2 – 3 days duration and advise patients to remain hydrated. 

• If longer-term use is required, check in with the patient at each new prescription to assess the need for continued use. The opioid dose or potency should be gradually titrated down as pain improves (as per treatment plan).  A link is provided to the Te Pou publication Substance withdrawal management: Guidelines for medical and nursing practitioners 

4.  Drug Driving

(i)  The Land Transport (Drug Driving) Amendment Act 2022 was introduced on 11 March, 2023.  The key changes, recommendations and resources are included in a recent Medsafe Alert.

(ii)  The key changes are the addition of Schedule 5 and new blood tests to measure the amount (concentration) of drugs in the blood.

• Schedule 5 contains 25 ‘listed qualifying drugs’ (4 illicit drugs and 21 prescription medicines). These drugs have been identified as having the highest risk to road safety.
• Police will continue to stop drivers at random to check for alcohol or drug driving. If a person fails a Compulsory Impairment Test (a behavioural test to check for impairment), they will be required to take a blood test to check for the presence of drugs. With the law change, blood concentration levels will also be measured for Schedule 5 drugs. The blood concentration determines the type of offence, which may be a fine, demerit points, licence disqualification, or a criminal conviction.

(iii)  If a qualifying drug is identified, a medical defence is available for the use of prescription medicines for drug driving offences:

• if the driver can demonstrate that they took the medicine according to a current and valid prescription from health practitioner, and
• they have followed any instructions from a health practitioner or manufacturer of the medicine.

(iv)  Advice for healthcare professionals

• Please discuss with your patients whether their medicines (both prescription and over the counter) could impair driving.
• Advise patients to check whether they have any side effects that could impair driving, and not to drive if these occur.
• Check section 4.7 of the medicine data sheet for the effects of a medicine on driving.
• Find the prescription medicines currently included in Schedule 5, for which blood concentration levels will be measured.

(v)  Points to consider

• MCNZ statement on good prescribing practice:  Ensure that the patient … is fully informed and consents to the proposed treatment and that he or she receives appropriate information, in a way they can understand, about the options available; including an assessment of the expected risks, adverse effects, benefits and costs of each option.

• Use of NZ Formulary Patient Information section and Patient Information Leaflets

• NZ Formulary Caution Advisory Labels (CALs) which are promoted by the NZ Pharmaceutical Society but do not appear to be a mandatory requirement

(vi) Additional resources

• Health Navigator Driving and medicines – contains both general and medicine-specific information for consumers including which medicines are most likely to affect driving, symptoms of impairment, when and how long to avoid driving  There is a special ‘Heavy transport and medication’ section included.
• NZ Police site explaining the new legislation from a consumer perspective
• Waka Kotahi information for consumers and  health professionals regarding substance impaired driving including a link to a substance impaired driving health professional CME online course

5. Phenobarbitone brand change

• Pharmac has notified the funded brand of phenobarbitone tablets (15 mg & 30 mg) is changing because a supplier is leaving the market.  Approximately 400 people in New Zealand take the drug.  Current stock is expected to run out in July.

• Patients taking phenobarbitone tablets for epilepsy require alerting to the impending brand change and required actions.  Two appointments with a healthcare provider are needed: at one month before (June 2023) and one month after the brand change.

• Serum phenobarbital testing is required to check that concentrations remain at the same level before and after the brand change. Testing is recommended:

• three weeks prior to the change
• within the week prior to the change
• within the first week of the change
• one month after the change

Laboratory reference ranges are for trough levels with test taken shortly before the scheduled dose.

• The brand change necessity may provide health professionals with an opportunity to review patient clinical management.  Funding is available from Pharmac to cover the patient co-payment for the two visits associated with this change.

• Waka Kotahi recommends that patients consider a voluntary driving stand-down period of eight weeks following an antiepileptic medication brand change.

• Detailed guidance on the brand change is available on the He Ako Hiringa website

6.   Take a breath

A recent Goodfellow Gem looked at two ways of breathing to improve mood/anxiety based on research from Stanford University which reported how the breathing exercises for 5 minutes per day were better for mood and anxiety than mindfulness meditation, where the breathing is just watched.   

• ‘Sighing’, characterized by deep breaths (a large breath and an extra inhalation) followed by extended, relatively longer exhales, has been associated with psychological relief, shifts in autonomic states, and a resetting of respiratory rate.
• ‘Box breathing’ or ‘tactical breathing’, which military members have used for stress regulation and performance improvement, is inhaling for a count of 4, holding for a count of 4, exhaling for a count of 4 and holding again for a count of 4. The researchers asked participants to breathe in through their noses and out through their mouths.